Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the clinical importance of differentiating between impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) states?
IGT and IFG are different phenotypes of prediabetes. Clinical studies* suggest that IGT may be associated with higher cardiovascular risk than IFG. The molecular mechanisms and the treatments are thus different. IGT, which is due to impairments of beta cell insulin release, can be treated with reduc...
How do you approach the use of hydroxychloroquine in patients with a history of visual field defect from another cause such as macular degeneration or diabetic retinopathy?
As Dr. @Dr. First Last noted, close collaboration with an ophthalmologist is critical, as the findings of HCQ-toxicity on advanced imaging with modalities such as an OCT can often be distinguished from other causes, and hence there is not an absolute contraindication in most cases. A few considerati...
How do you approach CV risk assessment in RA patients when RA itself is associated with some degree of increased CV risk at baseline?
I try to screen for the CV risk factors, present or absent. If present, I use the CV risk calculator, as an example the online Framingham risk calculator, and multiply the risk by a factor of 1.5-2 as proposed by EULAR, depending on whether the RA is active or inactive. Once you have a good assessme...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...
Do you have patients with recurrent calcium oxalate kidney stones stop taking supplements containing vitamin C if their 24 hour urine oxalate excretion is normal?
No. I am not aware of data that suggests Vitamin C would aggravate kidney stone formation in this situation. Stephen B. Erickson, MD
What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?
This is a very important and practical question. As with most clinical circumstances, there is no evidence-based recommendation. The approach will vary with individual situations. For example: 1) Incidentally discovered subsegmental PE: my bias would be to proceed with curative surgery after one mon...
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...
What evaluation do you do in patients with hypertension and persistently elevated aldosterone/renin ratio (over 20) but without an elevated aldosterone level (under 10 ng/dL)?
Patients with proven primary aldosteronism (based on pathology and postop aldosterone levels) can have plasma aldosterone levels <10 ng/dL. Repeating the levels, especially after optimizing their medications, can improve the test's sensitivity. The key in such cases is a PRA level <1 ng/dL. In the a...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...